Introduction: Change is already here.
The CMS 2026 Final Rule has been officially released and will significantly transform the way we operate within the Health Insurance Marketplace. If you are an insurance agent, now is the time to upgrade—not improvise.
Here's a straightforward explanation of what's changing, how it will affect you, and how you can continue delivering and selling with confidence.
1. Income verification: No more self-determination.
Starting in 2026, the IRS will not be able to verify your client's income. his word will no longer suffice. Valid documentation is required.
In addition:
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You will only have 90 days to correct inconsistencies (previously 150).
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If your customer does not reconcile the APTC when filing taxes in a single yearThe subsequent individual to forgo the subsidy will be deprived of it.
🔍 Palabra clave: verificación de ingresos CMS 2026
Automatic renewals: goodbye to the $0 inertia plan.
If the customer does not update his eligibility, he will be assigned a mandatory $5 premium.
They will no longer automatically relocate from bronze to silver.
💡 Key: respect the customer's choice and avoid operational errors.
3. New schedule for the Open Enrollment Period
Since 2027:
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It begins: November 1
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End: December 15 (in Federal Marketplaces)
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All coverage will begin January 1
🎯 Objective: continuous coverage and less confusion.
4. Elimination of SEP for low income (≤150% FPL).
This SEP was exploited by registrations without consent. Since 2026, it is completely eliminated.
📌 Change of income is no longer a valid reason for exceptional SEP.
5. SEP under scrutiny: mandatory prior verification
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75% of new enrollments per SEP must be verified prior to activating the policy.
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Applies only to (in Federal Marketplaces)
6. Coverage conditioned to the payment of previous premiums
If the client did not pay before, the insurance company may demand overdue payments + initial premium to activate new coverage.
💬 This strengthens consumer responsibility.
7. Changes in premium validation and eligibility
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Fixed thresholds are eliminated
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Only net percentage will be used to measure actual payment feasibility.
⏳ Effective until the end of 2026.
8. DACA falls off the radar
DACA recipients no longer qualify as legally present.
This excludes them from:
❌ QHP
Tax credits (APTC)
❌ Cost-Sharing Reductions
❌ BHP Programs
9. New restrictions in Essential Health Benefits (EHB)
The mandatory inclusion of sexual trait modification procedures in EHBs is limited.
But each state may establish its own exceptions.
10. Premium adjustments and plan design
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10. Premium adjustments and plan design
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The actuarial value (AV) is made more flexible to give more options to the consumer.
11. New standard for terminating agent contracts
CMS will now use the “preponderance of the evidence” to assess whether an agent should be removed for malpractice.
⛔ This means that, with less evidence, they can terminate your contract.
What about revenue justification? Use it well or lose the sale
When the IRS does not correctly reflect the client's income, You must use accepted documentation.
See the official CMS guide:c
🔗 How to resolve income inconsistencies
What should an agent do now?
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Strictly verifies documentation
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Educates the client about plan changes, payments and dates
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Avoid registrations without consent
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Make sure the client files taxes correctly
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Comply with the new regulations to avoid penalties
Conclusion: The well-informed agents survive, the prepared ones thrive.
These updates don't just change the rules of the game: they change the entire board. At V&L Insurance AgencyWe stay ahead of the curve so that our agents are always one step ahead.
Are you ready for what's ahead? We are.
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